Penile fracture: emergency tunica repair

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. The buckling moment The erect penis buckles against the perineum or the pubic arch during vigorous intercourse or manipulation, and the story is characteristic. There is an audible or felt crack, sharp pain, immediate loss of the erection and a bruising swelling that tracks along the shaft. While the deep fascia holds, the haematoma is confined to the shaft, which is why the deformity follows the penis rather than spreading to the scrotum and abdominal wall. The direction of the bend identifies the side put under tension, because the tunica tears opposite the bend rather than on it, and that geometry is recorded because it predicts the site the operation will find.
   where it bites: the tunica tears on the tensile side, opposite the bend; the tear site is predicted from the direction of the injury.
2. Assessment + selective imaging The history usually carries the diagnosis and the examination confirms it: a bent, bruised, tender shaft with a classic story needs no imaging before theatre. The meatus is examined for blood at first contact and the patient is asked directly about voiding. Blood at the meatus, a spraying stream or retention means the urethra is injured, and the operative plan changes. Imaging is reserved for atypical stories and the genuinely equivocal examination, where it separates a true corporal tear from a rupture of the dorsal vein alone, and the meatal findings are documented before consent. The animation shows the urethral check as a schematic retrograde urethrogram: a catheter tip in the fossa navicularis with the balloon just inflated (typical), contrast running back to the bladder, and any extravasation at the fracture level declaring the urethral injury before anyone passes an instrument blind.
   where it bites: blood at the meatus, a spraying stream or retention means the urethra is injured and the operative plan changes.
3. Subcoronal degloving A circumferential subcoronal incision is made and the shaft skin is degloved down to the root in one sleeve, lifting skin and subcutaneous tissue together off the deep fascia. The plane stays on Buck's fascia throughout, which keeps the dissection clean and keeps the dorsal neurovascular bundle at 12 o'clock out of harm at both incision and closure. Degloving to the root is the point of the approach: it exposes the whole haematoma for evacuation and both corpora for circumferential inspection, not merely the site the bruise points to. A degloving stopped short of the root hides the proximal tear at the penoscrotal junction, which is the classic miss.
   where it bites: the degloving plane stays on Buck's fascia; the dorsal neurovascular bundle at 12 o'clock is respected at incision and closure.
4. Haematoma evacuation Clot is evacuated systematically with suction and swabbing until the tunica of both corpora can be seen, because the haematoma distorts everything beneath it and no judgement is made on a dirty field. Each corporal body is then inspected through its full circumference, and the tear presents as a transverse defect on the ventrolateral corporal body within the ten to two o'clock arc. The haematoma is followed to its deepest point, since the tear usually sits at the base of the clot. A second tear is excluded before any repair begins, because stopping at the first defect with the penis partly degloved is the incomplete operation.
   where it bites: a second tear is excluded before repair begins; the classic miss is stopping at the first defect with the penis partly degloved.
5. Tunica repair + urethral inspection The tear edges are freshened back to healthy tunica and closed with interrupted fine absorbable sutures, taking careful shallow bites so the repair is watertight without bunching. Deep bites are the trap of this step: dorsally they threaten the neurovascular bundle at 12 o'clock, and ventrally they threaten the urethra, which may already be torn. When the meatus showed blood or the history suggests urethral involvement, the urethra is inspected over a catheter or with the scope before any wound is closed. Finding the injury on the table converts an accident into a planned two-structure repair, documented with sites and the catheter plan.
   where it bites: deep bites dorsally threaten the neurovascular bundle; ventrally they threaten the urethra that may already be torn.
6. Closure + counselling The degloved skin is returned to its natural position, a light non-constricting dressing is applied with the penis elevated, and the dressing is checked to be sure it does not compromise the glans. Haemostasis is confirmed once more before closure, because a re-formed haematoma beneath the flap is the commonest early reason for a return to theatre. Counselling before discharge covers the realistic course: bruising and swelling that settle over the following weeks, a scar at the coronal margin, the possibility of later curvature, and an honest account of erectile recovery. The conversation is documented, because the patient warned at discharge is the patient who does not return angry.
   where it bites: unrealistic expectations about immediate function do more damage than the repair; the conversation happens before discharge.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance